Treatment of the neglected and deadly "black fever"
When 25-year-old Sunder Devi reached the hospital in Hajipur in the Indian state of Bihar, she was more dead than alive. Like so many in Bihar, she was suffering from kala azar (visceral leishmaniasis), also known as "black fever". The region has the highest prevalence of the disease in the world. “When patients like Sunder Devi come to us they have mostly been suffering for weeks from fever, tiredness, loss of appetite, and weight loss. Just by touching their bellies, you can tell that the spleen is greatly enlarged,” explains Gaurab Mitra, an Indian doctor who works with MSF in the kala azar ward at the hospital in Hajipur.
A patient on the kala azar ward at Sadar Hospital in Hajipur in Bihar. India, 2008.
Mischa Friedman
What begins with flu-like symptoms develops
over a period of months into a life-threatening illness. The infectious agent – a parasite which is transmitted by sandflies – damages the immune system, making the sufferers susceptible to other diseases such as pneumonia or tuberculosis. Not only that, but they additionally suffer from acute anaemia. It takes weeks after the onset of the disease for the typical symptoms to fully emerge: a swollen abdomen, anaemic skin pallor and wasted extremities.
Even though the disease is life-threatening and affects tens of thousands of people, it hardly attracts any public attention at all. The World
Health Organisation (WHO) classes kala azar – along with 13 other diseases – as a “neglected tropical disease”. Very few institutes or pharmaceutical companies are investing time and money into researching it, with the consequence that very few new drug treatments are being developed – and there is no vaccine. One reason for this is that neglected tropical diseases like kala azar primarily affect people in poorer countries, which represent an unattractive market because most of their inhabitants cannot afford to pay for expensive drugs.
A girl waits outside Sadar Hospital in Hajipur in Bihar. India, 2008.
Mischa Friedman
This is reflected in the hospital in Hajipur. Many of the kala azar sufferers belong to the lowest Indian caste: the Musahar. “These people are the poorest of the poor. They work as casual labourers in the fields or tend cattle. They sleep in huts of mud and straw and are thus especially vulnerable to the bites of the sandflies,” says Gaurab Mitra. “Whereas it is true that the sufferers can find help in the national health centres, they are frequently only treated using outdated drugs.”
Such a drug is Pentostam, which was developed in the 1930s. Treatment with Pentostam requires a painful course of injections directly into the muscles over a period of up to 40 days – with numerous side effects. This treatment is, in any case, often fruitless: in some parts of India where the disease is endemic, over 60 per cent of the pathogens have developed a resistance to this antiquated drug.
MSF in Bihar is therefore using a newer drug, known by the brand name Ambisome®. “This is a very good drug. We have treated around 1,700 patients with it since July 2007. Sufferers can recover in as little as ten days,” says Gaurab Mitra. “In Sunder Devi’s case it took somewhat longer because she was also infected with hepatitis. But we were still able to discharge her after four weeks.”
MSF treat a young boy with kala azar at Sadar Hospital in Hajipur in Bihar. India, 2008.
Mischa Friedman
However, even the Ambisome® drug has a disadvantage: its cost. Even after a sharp fall in price, it still costs about US$280 to treat each patient. This is a price which many people in poorer countries are unable to pay, making it more difficult to establish the widespread use of the drug in Indian health centres.
It is for this reason that MSF’s access campaign
is challenging the pharmaceutical industry to make further reductions in the price of Ambisome® and not to prevent the production of cheaper combination drugs. MSF is also calling on governments to make more money available for research into neglected diseases and to push for the development of improved testing procedures, drugs and preventative vaccines, in the hope that in the future we will see more patients like Sunder Devi returning home restored to full health after successful treatment.
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MSF has worked in India since 1999. 80 percent of the world's cases of kala azar are found in India. 90 percent of these cases are found in the state of Bihar, where MSF has helped to rehabilitate a focused kala azar programme for treating people with complicated cases of the disease.